Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Alternative Medicine, Wishful Thinking, and Irresponsible Drug Pushers

 

Most emergency physicians avoid using homeopathy, acupuncture, Reiki, and other alternative medicine because there is no valid evidence that these treatments work, or because of they are not considered standards of care, or because there is no recommendation to give them from ACEP (American College of Emergency Medicine).

This is good, because alternative medicine is fraud.

Is there an alternative field of aerodynamics making planes for us to fly? Where is this alternative science?

Are people using alternative electricity to power their homes? Where is this alternative science?

According to the homeopathy hypothesis, the more dilute something is, the more powerful it is. We could solve the world’s energy problems – if the alternative science of homeopathy were anything more than wishful thinking.
 

How does that relate to emergency medicine?

When it comes to emergency treatments for cardiac arrest, stroke, heart failure, possible spinal cord injury, et cetera, many emergency physicians are just as superstitious as your local witch doctor. Currently, the most prominent example of alternative emergency medicine is tPA (Alteplase) for acute ischemic stroke.
 

But tPA, approved for strokes in 1996, only works if given within 4.5 hours of a stroke.[1]

 

That is an optimistic interpretation of the research –
 

The recent release of the American College of Emergency Physicians guideline recommending the use of tPA for ischemic stroke is remarkable. While it is unsurprising that a professional guideline flouts science, the publication is striking for its casual tone and its methodologically inexplicable review of evidence. Scientific thinking is absent.[2]

 

The evidence is horribly flawed, but the advocates respond just as we expect alternative medicine pushers to respond – with logical fallacies.

Ad hominem attacks on those who criticize the bad research.
 

These few persistent myths about thrombolytic therapy were first promulgated by self-appointed ‘expert critics’ who are unabashedly anti-intellectual in their opposition to this therapy. They decline to either read or attempt to understand data and rigorous analysis of that data.[3]


Alternative medicine pusher Dr. Patrick Lyden.
 

What is the appropriate time period for giving tPA?
 


IST-3 time to treatment randomization and outcomes detail with my edits for clarity.[4]
 

Patients get better if tPA is begun within 3 hours, get worse if tPA is begun between 3 hours and 4 1/2 hours, but get better when tPA is begun after more than 4 1/2 hours.

Clearly, there is some strong evil magic that is working against tPA in that 3 to 4 1/2 hour time period, but it is all unicorns and rainbows the rest of the time.

Does that make sense?

No.

That suggests that the evidence we have does not adequately assess the effects of tPA for acute ischemic stroke.

Reasonable people can disagree, but Dr. Lyden appears to be calling those who disagree biased just because they disagree. This is bad science and bad medicine.

We need research that is well controlled, not research that requires a lot of excuses.
 

MedPage Today is providing a good forum for discussion of this actual medical controversy and not just promoting the ad hominem criticisms of Dr. Lyden. There are links to plenty of other sites discuissing the problems with the evidence.[5]

I most recently wrote about this here – The Debate on tPA for Ischemic Stroke at EMCrit – What Does the Research Really Say?

I am not an emergency physician, so this is not something that affects my care of patients. I do not have to worry about being sued for not giving tPA and being accused of allowing a bad outcome. I do not have to worry about being sued for giving tPA and being accused of producing a bad outcome.

If you are an ACEP member, tell ACEP what you think of the evidence, or the flaws in the evidence.

Footnotes:

[1] Few stroke patients get clot-busting drug
Liz Szabo,
USA TODAY
10 a.m. EST February 13, 2014
Article

[2] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM
Article

[3] ER Briefs: tPA ‘Works’, ACEP on Target
Published: Feb 10, 2014
By Elbert Chu
Interview with Patrick D. Lyden, MD
Article

[4] The benefits and harms of intravenous thrombolysis with recombinant tissue plasminogen activator within 6 h of acute ischaemic stroke (the third international stroke trial [IST-3]): a randomised controlled trial.
IST-3 collaborative group, Sandercock P, Wardlaw JM, Lindley RI, Dennis M, Cohen G, Murray G, Innes K, Venables G, Czlonkowska A, Kobayashi A, Ricci S, Murray V, Berge E, Slot KB, Hankey GJ, Correia M, Peeters A, Matz K, Lyrer P, Gubitz G, Phillips SJ, Arauz A.
Lancet. 2012 Jun 23;379(9834):2352-63. doi: 10.1016/S0140-6736(12)60768-5. Epub 2012 May 23. Erratum in: Lancet. 2012 Aug 25;380(9843):730.
PMID: 22632908 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.

[5] ER Briefs: Open Season on ACEP tPA Guidelines
Published: Jan 29, 2014 | Updated: Jan 30, 2014
By Elbert Chu
Article
.

Comments

  1. I had some Con-Ed taught by a neurosurgeon who specializes in, and researches, stroke care. What he emphasized to us was:

    * In any ischemic stroke, there is the part of the brain which is already dead (umbra), and the part of the brain which is actively dying (penumbra).
    * Appropriate use of advanced imaging (fMRI, CT, whatever) allows us to know how much of which exists.
    * Permanent damage occurs as the penumbra region converts to umbra (actually dies).
    * The purpose of tPA and similar is to revascularize the penumbra so as to prevent it from dying.
    * The rate at which the penumbra region converts to umbra is highly variable.
    * If there is little or no penumbra left, there is no reason to use tPA – you only get the side-effects.

    So, the 3 hour or 4.5 hour rule is really a guideline based on averages of highly variable numbers. The doc involved has had patients who’ve had substantial, immediate improvement from tPA after waiting several days before administration. Likewise, he’s had patients at the 90 minute mark where there was nothing to salvage with tPA. Takeaway: get the pt. to a stroke center right away so that the optimal treatment can be pursued.

  2. While we don’t administer the tPA and thus “it doesn’t matter”, it does if we are trying to beat the clock for no real purpose. Crews are expediting transport (high risk) to get a patient to the ER within a window of time for a questionable benefit.

    • Jon,

      Crews are expediting transport (high risk) to get a patient to the ER within a window of time for a questionable benefit.

      We are rushing patients with new onset of neurologic symptoms to the hospital.

      Fibrinolysitic treatment is not the only option, but we should transport safely.

      However, throwing a patient around in the back of an ambulance and keeping a siren on are probably not therapeutic.

      .

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